Friday, August 28, 2015

(From time to time, the Disease Management Care Blog welcomes commentary from its readers. Here's an interesting thought.....)

As a long-term reader, I thought the erudite but contrarian and sometimes snarky DMCB might be the best venue to ask others of my ilk to comment on an observation of mine.

I am a primary care provider working at the quantum level of patient care. I am in my second year of full fledged EHR use. It is obvious to me from the consultation notes that I receive on an hourly basis that most of my colleagues are also on board. Journal articles as well as my first-hand experience have convinced me that we have indeed reached the tipping point of electronic record use.

Since this milestone passed, I have noticed a change in the focus of office notes and consults. I am seeing neurosurgeons document conversations regarding the safety of patients relationships and whether or not they feel threatened. Podiatrists routinely document the existence of living wills. Dermatologists are now savvy about the sexual activity of octogenarians with actinic keratosis. Despite my consultants' thoroughness in their care (and conversations with health care students who have rotated through these specialties make me believe that some specialists are using telepathy to document things), I am not seeing traditional assessment and plans at the end of the encounter.

What I usually see is the same generalized diagnosis code that I sent them with followed by a list of tests cluttered with a references to various quality metrics that are inspired by systems such as HEDIS®. The old fashioned differential diagnoses or thoughtful prose concerning the evaluation is conspicuously absent.

I call this my hypoplastic hypothesis.

As a primary care physician, when I consult a colleague, I am really asking the specialist “Hey, what do you think?” Prior to the advent of the EHR, much of my continuing medical education has come from the insights that I use to get from these consults. Now I'm reading about feeling threatened, living wills and sexual activity.

How did we get here?

When I was an undergrad in Biochemistry, during the dreaded Physical Chemistry course, we learned about the observer effect and the Heisenberg uncertainty principle. Wikipedia defines both as:

"In science, the term observer effect refers to changes that the act of observation will make on a phenomenon being observed. This is often the result of instruments that, by necessity, alter the state of what they measure in some manner. A commonplace example is checking the pressure in an automobile tire; this is difficult to do without letting out some of the air, thus changing the pressure. This effect can be observed in many domains of physics.....However in quantum mechanics, which deals with very small objects, it is not possible to observe a system without changing the system, so the observer must be considered part of the system being observed.In quantum mechanics, the uncertainty principle is any of a variety of mathematical inequalities asserting a fundamental limit to the precision with which certain pairs of physical properties of a particle known as complementary variables, such as position and momentum, can be known simultaneously. For instance, the more precisely the position of some particle is determined, the less precisely its momentum can be known, and vice versa."

In my opinion we now have a new phenomena that parallel the laws of physical chemistry: I call it the HEDIS uncertainty principle.

The actual act of measuring HEDIS® scores and other similarly contrived quality metrics has fundamentally intruded into the quantum level of physician care. Does this measurement change the behavior of the particles of the system and alter the ultimate structure of the encounter? Are the data still reliable and the measurements still accurate? Have the impressions and treatment recommendations indeed become hypoplastic, or has the encounter remained unchanged but the documentation is skewed to HEDIS®? Is the question asked of the consultant answered but not documented? If not, what does this portend for disease management and health care quality?

I have my suspicions, but I would like to tap the wisdom of the DMCB readers for theirs.